On behalf of the EuroHOPE-team: Terje P. Hagen

1. The EuroHOPE- project: Comparison of treatment and outcome for AMI and stroke patients in Europe On behalf of the EuroHOPE-team: Terje P. Hagen Department of Health Management and Health Economics, The Medical Faculty, University of Oslo

2. Approaches to international efficiency comparisons prior to EuroHOPE • System level analysis • WHO 2000, Afonso and St. Aubyn 2005 • Challenges in output measurement: How to measure the impact of health services on health? • Disease level analysis • McKinsey healthcare productivity study, OECD aging-related disease (ARD) project, Technological Change in Healthcare (TECH) Global Research Network (AMI) • Possible to relate inputs to outputs but requires nationally representative patient level data • Sub-sector level analysis • Nordic hospital comparison study group (NHCSG) • Requires that units are comparable and inputs and outputs can be measured in a similar way iHEA meeting, 8th of July, Sydney. Contact: timo.t.seppala@thl.fi

3. What and how EuroHOPE does it? • Applies both the disease level and the sub-sector level approaches • Develops methods to measure outcomes and costs of care of specific diseases for evaluation of care given in the whole treatment chain (not yet primary care due to lack of data) • The methods can be used for • routine performance evaluation and monitoring • establishing recommendations for lists of indicators to be routinely collected and published by the EU (as a part of European Community Health Indicators) iHEA meeting, 8th of July, Sydney. Contact: timo.t.seppala@thl.fi

4. Solutions in EuroHOPE • Definitions of specific patient groups to maximize comparability • Extensive risk adjustment • Standardisation by modelling and computing confidence intervals • Definitions of episodes EFPC, Istanbul, 2013

5. EuroHOPE Data Comparison of countries, regions and hospitals EuroHOPE research National EuroHOPE database National EuroHOPE comparison data International EuroHOPEcomparison data National discharge register National mortality register Other national registers Protocols Anonymous individual level data used for comparative research National research and bencmarking

6. Total episode of care Firsthospitalepisode Admission to ward A Admission to ward B Discharge home ornursinghome Outpatient visit time Procedure/treatment in ward A Discharge to another hospital Medication purchase Definitions of episodes EFPC, Istanbul, 2013

7. Risk adjustments based on comorbidities (AMI) EFPC, Istanbul, 2013

8. Description of regions used in EuroHOPE EFPC, Istanbul, 2013

9. Acute Myocardial Infarction (AMI) • inpatient, outpatient, medication administrative data and death registries • AMI codes: ICD-9: 410, ICD 10: I21, I22 • inclusion criteria: valid ID, resident, age 18-X • index hospital admission: • main diagnosis is AMI, no AMI within 365 prior the admission • linkage of individual episodes with patient IDs • first analysis: • FIN, HUN, IT, NL, SCO , SWE - 2007 • NOR - 2009 EFPC, Istanbul, 2013

10. 2-day PCI rate (%) of AMI patients by country, adjusted for age and sex EFPC, Istanbul, 2013

11. 2-day PCI rate (%) of AMI patients per region by country, adjusted for age and sex, with confidence intervals NETHER- LANDS FINLAND HUNGARY NORWAY SWEDEN EFPC, Istanbul, 2013

12. Mean length of first hospital episode of AMI patients per region by country, adjusted for age, sex and previous year hospital days, with confidence intervals ITALY FINLAND HUNGARY NORWAY SWEDEN EFPC, Istanbul, 2013

13. One-year mortality of AMI patients per region by country, adjusted for age and sex, with confidence intervals EFPC, Istanbul, 2013

14. Ischaemic stroke • inpatient, outpatient, medication administrative data and death registries • Ischaemic stroke codes ( ICD-9: 433-434, ICD 10: 63 • inclusion criteria: valid ID, resident, age 18-X • index hospital admission: • main diagnosis is ischaemic stroke, no stroke within 365 prior the admission • linkage of individual episodes with patient IDs • first analysis: • FIN, HUN, IT, NL, SCO, SWE - 2007 EFPC, Istanbul, 2013

15. Mean length of first hospital episode of stroke patients per region by country, adjusted for age, sex and previous year hospital days, with confidence intervals ITALY FINLAND HUNGARY SWEDEN EFPC, Istanbul, 2013

16. Meanmortality (30-, 90-day and one-year (%)) of strokepatientsby country, adjusted for age and sex EFPC, Istanbul, 2013

17. Mean one-year mortality of stroke patients per region by country, adjusted for age and sex, with confidence intervals FINLAND HUNGARY NETHERLANDS SCOTLAND SWEDEN EFPC, Istanbul, 2013

18. Conclusions • Large variation in use of resources and outcomes between the countries, hospitals and regions • Potential for improving efficiency • Benchmarking (where is the wisdom): preliminary best performing regions in EuroHOPE countries EFPC, Istanbul, 2013

19. Next steps • National and regional indicators to be published at http://www.eurohope.info • Development methods for measuring costs • Scientific articles (clinical, methodological, health policy orientated) • Health economic issues such as • analyses of reasons behind differences in outcomes and use of resources between the countries and regions • relationship between outcomes and cost at country and hospital level EFPC, Istanbul, 2013